Drug and Hiv & Aids

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SUBSTANCE ABUSE IN SOUTH AFRICA:

COUNTRY REPORT

FOCUSSING ON YOUNG PERSONS

Prepared for the WHO/UNDCP Regional Consultation - Global Initiative onPrimary Prevention of Substance Abuse Among Young People,

Harare, Zimbabwe, 24-26 February 1998

Charles DH Parry, PhDMental Health & Substance Abuse, Medical Research Council

PO Box 19070, 7505 Tygerberg; South [email protected]; Fax: +27-21-938-0342


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South Africa Report, pg. 2

1. INTRODUCTION

South Africa is the southern most country in Africa and has a population ofapproximately 38 million persons, distributed over nine provinces ranging inpopulation from 746 000 (Northern Cape) to 7 672 000 (KwaZulu-Natal). It isestimated that 55.4% of the population reside in urban areas (Central StatisticalServices, 1997). Table 1 gives an indication of the percentage of the populationfalling in different age bands. There has been considerable controversy in SouthAfrica with regard to what constitutes a young person, with the Youth League of theAfrican National Congress for example, allowing into membership persons up to 35years of age. Regardless of ones definition of what constitutes a young person it isclear from Figure 1 that at least half the population of South Africa can probably becategorised as young people .

Law enforcement authorities, service providers and substance abuse researchers

are in agreement that the nature and extent of illicit drug trafficking, consumptionand associated problems have all increased dramatically during the 1990s as thecountry has gone through a major political and social transformation and as tradeand other links have open up with other African countries and the rest of the world.The change with regard to substances such as alcohol and tobacco has been lessdramatic, but due to the enormous burden to society caused by the use of thesesubstances, prevention efforts should not only be directed towards illicit substances.This report, in particular, focuses on alcohol and other drugs (AODs), and givesspecial attention to young persons.


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2. SUBSTANCE ABUSE AND RELATED HEALTH AND SOCIALPROBLEMS IN SOUTH AFRICA

2.1 Systems/mechanisms to collect substance abuse information

Historically South Africa has not had very reliable systems in place to facilitate thecollection of data relating to substance use. To date, much of the availableinformation has come from ad hoccross-sectional research studies often conductedin a single location and from information on police arrests and seizures. This hasbeen supplemented by occasional national surveys. Apart from the police arrestand seizure data, which is greatly influenced by factors such as resources availableand particular policing policies and initiatives, there has been no longitudinal

information available on trends in illicit drug use. With regard to alcohol, the onlynational trend data available are (i) information on adult, per capita annual absolutealcohol consumption from 1985, (ii) information on the results of annual testing ofalcohol levels among drivers and pedestrians from 1975, and (iii) a single studycomparing consumption of absolute alcohol among different populations in 1982 and1985 (Rocha-Silva, 1989).

As stated, the predominant way in which information on AOD use has beencollected in South Africa has been via ad hocresearch undertaken by researchersfrom one of the science councils (the Medical Research Council (MRC), the HumanSciences Research Council (HSRC) or the Council for Scientific and Industrial

Research (CSIR)), or from universities (e.g. Cape Town, Stellenbosch and Durban-Westville) or from NGOs (e.g. the Centre for Alcohol & Drug Studies, the SouthAfrican National Council on Alcoholism and Drug Dependence (SANCA), theInstitute for Health Training and Development (IHTD) and the South African BrainResearch Institute (SABRI)). Funding has largely come from the Centre for ScienceDevelopment, the MRC, the Department of Welfare and individual universities.

Several new systems have been initiated which should lead to more valid andreliable information on AOD use in future. These include:

The South African Community Epidemiology Network on Drug Use (SACENDU)

SACENDU is a network of persons from a variety of different sectors (e.g. lawenforcement, health and welfare treatment services, and public health research) thatmeets biannually to present and discuss information about existing and emergingAOD abuse patterns and trends. The network, currently comprising over 50organisations in four sentinel sites, was established by the MRC in collaborationwith the University of Durban-Westville in 1996 with the technical assistance of theWorld Health Organization s Programme on Substance Abuse (WHO/PSA) and theUS National Institute on Drug Abuse (NIDA). Start up funds for SACENDU wereprovided by WHO/the United Nations Development Programme (UNDP) and theMRC. It now comprises three port cities (Cape Town, Durban and Port Elizabeth)and Gauteng Province (which includes Johannesburg and Pretoria). Indicators usedin Phase I of the SACENDU Project, together with the type of data (primary orsecondary), the data source and frequency of data collection are listed in Table 1.


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Data sources have included specialised treatment centres, acute psychiatricadmissions units, the police, and mortuaries. Here the focus has been on collectingsecondary data. Primary data have also been collected via qualitative research

(involving sex workers, persons attending rave parties, street children andpharmacists), school surveys, and trauma unit studies (Parry, Bhana, & Bayley,1997).

The Crime Information Management Centre (CIMCThis centre was established in 1996 and is tasked with the coordination,processing, analysis and interpretation of crime information and intelligence in orderto facilitate the combatting of crime by means of effective and holistic crimeinformation management (CIMC, 1997). On a quarterly basis CIMC releasesnational, provincial, and district -level statistics by 32 crime categories, includingdrug related crime and driving under the influence of alcohol or drugs .

Unfortunately data are not yet broken down by the age of the offender.

The South African Alliance for the Prevention of Substance Abuse (SAAPSA)SAAPSA was established in 1995 with the assistance of WHO/PSA, theInternational Council on Alcohol and Addictions (ICAA), and the InternationalOrganisation of Good Templars (IOGT) and includes members from over 70organisations. Its goal is to facilitate networking amongst all organisations,government and civil society, concerned with drug and alcohol abuse in South Africawith the view to optimise cooperation in the prevention and treatment of alcohol anddrug abuse in order to improve the quality of life and to promote peace anddevelopment for all South Africans (Turner, 1996, p. 7).

The South African Researcher-Practitioner Association (SARPA)SARPA comprises over 50 government departments, private institutions as well asCBOs. Its vision is to sustain an inclusive multi-sectoral forum of researchers andpractitioners that facilitates community-driven research based policy formation andservice provision regarding drug-related prevention and treatment in South Africa(Drug Advisory Board, 1997, p. 22). The HSRC is one of the driving forces behindSARPA.

National Information System for Social Welfare (NISWEL)

For several years now there has been some discussion by the Department ofWelfare with regard to the development of a National Information System for SocialWelfare which among other things would include national level indicators onsubstance abuse treatment demand and prevention services. This system is not yetfully operational.


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SouthAfric

aReport,pg.

5

T

ABLE1

SACENDU:

Indicators,datasourcesand

frequencyofdataco

llection

INDIC

ATOR

TYPE

SOURCE

FREQUENCY

NATU

REAND

EXTENTOFAOD

USE/AB

USE

Prima

rysubstanceofabuse(aswellassecondary

drugs

used,modeofadministration,referra

lsource,

typeo

ftreatment,severity,monthlyspendingon

AODs

)

2ary

Allspecialist

treatmentcentres

Continuous-6m

onths

ATOD

use

1ary

1ary

2ary

-Schoolsurveys(representativesampleGrades8

and11)

-Interviewsw

ithdrugusers(streetchildren,ravep

artyattenders,

commercialsexworkers)&pharmacists

Alcoholtestin

gdrivers/pedestrians(fromC

SIR)

1Xperyear

2Xperyear

1Xperyear

CONS

EQUENCESOFAOD

USE

AOD-

relateddeaths

2ary

Mortuarysurveillance:bloodalcohol&drugODmentions(from

UCT/U

Stelle

nboschForensicMedicine)

Continuous-12

months

AOD

arrests/seizures

-Drun

kdriving(collision/nocollision)

-Dealingindrugs(arrests,unitsseized,price,

purity)

-AOD

useamongarrestees

2ary

2ary

1ary

CrimeInform

ationManagementCentre

CrimeInform

ationManagementCentre,SANAB

MRC/SANCA

/InstituteforSecurityStudies:usingblood/urine

analyses

Continuous-6m

onths

Continuous-6m

onths

TBA

AOD-

relatedtraumamentions

1ary

Studyofpatients1publichospital-2idealizedwe

eksover2

months:brea

th(alcohol),urine/sweat(drugs)

1Xperyr

AOD-

relatedpsychiatricconditions

2ary

Review

intake/dischargeinformationfrompublicpsychiatricfacilities

(alcohol/drug

-relateddiagnosesasproportionofotherdiagnoses)

Continuous-6m

o.

Continu

ous--12mo.meansthedataiscolle

ctedcontinuously,butonlyreportedonceevery12months

1ary=

primary;2ary=secondary


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2.2 Nature and extent of substance use in South Africa

2.2.1 Overview

2.2.1.1 Range of substance usedAODs used and abused in South Africa can be roughly divided into threecategories, those which are extensively used, those which are moderately used, andthose which are less frequently used. In the first category, alcohol remains the mostcommonly abused drug in South Africa, followed by dagga (cannabis) and thedagga/Mandrax ( white pipe ) combination. Mandrax (Methaqualone) is sometimesalso used on its own. There is also considerable abuse of over-the-counter andprescription medicines (e.g. pain relievers, tranquillizers (includingbenzodiazepines), cough mixtures (containing codeine), and slimming tablets), aswell as solvents (especially glue)). In the second category one finds drugs such as

crack cocaine, cocaine (powder), heroin, Speed, LSD, hashish and Ecstasy(MDMA). Crack cocaine may well need to be placed in the first category in the nearfuture. In the latter category are drugs such as opium, Rohypnol (Flunitrazipam),Ketamine, and Wellconal. Many substance users in South Africa are poly-substanceusers (e.g. using various drugs in combination with alcohol as well as othercombinations, such as cocaine and heroin). In terms of pharmacological properties,the substances most abused in South Africa are depressants (e.g. alcohol, whitepipes , Mandrax, benzodiazepines) followed by hallucinogens (dagga, LSD, Speedand Ecstasy).

South Africans consume well over 5 billion litres of alcoholic beverage per year. The

figure could be nearer to 6 billion litres, depending on one s estimate of the amountof sorghum beer consumed. Roughly two-thirds of the absolute alcohol consumedin South Africa is malt or sorghum beer. In terms of alcoholic beverage thistranslates to roughly 4.2 billion litres or roughly 90% of the alcoholic beverageconsumed. Roughly 15% of the absolute alcohol consumed is wine. See Figure 2.


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2.2.1.2 Prevalence of AOD useThe overall prevalence of alcohol misuse is likely to be as much as 30% amongcertain groups and as low as about 5% in others, and is dependent on factors such

as age, gender, socio-economic status and degree of urbanisation. Binge drinkingamong young people, especially males is high (in excess of 25% in manycommunities). High levels of alcohol misuse have been reported among personsinvolved in certain occupations (e.g. farming and mining) and among residents ofdisadvantaged communities where there is easy access to alcohol (Parry &Bennetts, in press). Adult per capita consumption of absolute alcohol in SouthAfrica is between 9 and 10 litres per year which places the country among the higheralcohol consuming nations. Since 1993 the level of per capita adult absolute alcoholconsumption appears to be rising, after a decrease in 1990 and 1991 (see Figure 3).

Accurate national statistics on the prevalence of the use of illicit drugs and on theinappropriate use of over-the-counter or prescription medicines ( lifetime use, use

in last 12 months , and use in last 30 days ) are currently not available. Use of illicitdrugs in the last 30 days may well be as high as 20% in certain communities,particularly considering rates of dagga and dagga/Mandrax use. There is clearly aneed for regular household surveys to be conducted to assess illicit drug use,preferably at a national level or else in selected sentinel surveillance sites. Anational household health survey will be held in early 1988, but it only asks aboutalcohol and tobacco use.


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2.2.1.3 Frequency of useWeekend drinking is particularly prevalent. Table 2 provides an indication of theproportion ofcurrent users who use various substances at least once a week :

Table 2: Percentage of current users who reported consumption of varioussubstances of at least once a week : Africans (Rocha-Silva et al., 1996)

Malt

beer

Sorghu

m beer

Wine Distilled

spirits

Dagga

Metros* Male 79 77 60 51 13

Fem ale 71 46 38 43 -

Towns* Male 87 69 44 54 75

Fem ale 75 - 50 56 -

Squatters

*

Male 85 70 72 66 17

Fem ale 74 - 56 52 -

Urban** Male 44 9*** 33 46 67

Fem ale 35 5*** 23 50 -

Rural** Male 69 35*** 45 49 -

Fem ale 43 18*** 29 - -

* - Persons 14+, ** - young persons 10-21 years old, *** - home made liquor (not just beer)

2.2.1.4 Mode of ingestion

Excluding alcohol and prescription and over-the-counter medicines, the mostcommon means of ingestion of drugs in South Africa is smoking (sometimesreferred to as batting ). Rates of drug injection are low at present. Drugs such asSpeed are being snorted ( snarfing ) and swallowed.

2.2.1.5 Characteristics of substance usersIn terms of AOD use patterns, difference have been noted with regard to age, social

class, occupation, school-status, gender and geographic location. This isdemonstrated, for example, by the following information/research findings:

AGE: Treatment demand statistics suggest that use of drugs such asEcstasy, LSD and Speed are more common among younger persons thanamong older persons. Solvent use is also higher among young persons.Patients in specialised treatment centres whose primary substance of abuseis alcohol tend to be older than those whose primary substance of abuse isthe dagga/Mandrax ( white pipe ) combination who in turn tend to be olderthan persons whose primary substance of abuse is dagga on its own. (Parryet al., 1997). Among school going youth alcohol use appears to increase withage for both males and females (Flisher, Ziervogel, Chalton & Robertson,1993a).


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Gender: AOD use is more prevalent among males than females (Parry et al.,1997, Tibbs, 1996). Gender differences, however, appear to be less markedfor drugs such as heroin and cocaine (Parry et al., 1997).

Socio-economic status: Use of drugs such as dagga/Mandrax and solvents(e.g. glue) are more common among persons from less advantagedcommunities, whereas use of drugs such as cocaine and Ecstasy is moreprevalent among persons from middle- and upper-class communities. Drugssuch as Ecstasy and LSD, and to some extent Speed and hashish, are usedat rave parties (Parry et al., 1997).

Occupation : Drugs such as alcohol, dagga, crack and Mandrax arefrequently used by sex workers (Parry et al., 1997). High levels of alcoholuse and misuse have been reported among workers in the mine industry and

among workers in the fruit and wine farming industries. Higher levels ofbinge drinking have been reported among high school drop-outs than amongstudents of similar age who are still attending school (Flisher & Chalton,1995).

Geographic location: The highest use of the white pipe combinationoccurs in the Western Cape. Crack cocaine and heroin use are likely to beused more frequently in urban as compared to rural areas. In comparison toCape Town and Port Elizabeth, the most frequent cases of Rohypnol use anduse of cocaine/heroin in combination have been reported by personsattending treatment centres in Durban (Parry et al., 1997). With regard to

alcohol, research among Africans 14 years and older has found greater levelsof risky drinking among residents of squatter settlements, metropolitan areasand towns than among the more rural populations in the previouslydesignated homelands (Rocha-Silva 1991a/b). Conversely, research amongAfrican young persons aged 10-21 years reported the highest levels of riskydrinking among rural as compared to urban populations.

Various studies (e.g. Rocha-Silva, 1989; Rocha-Silva et al., 1996) suggest that cleardifferences exist between different age, gender and race groupings with regard tothe types of alcoholic beverages consumed and to the proportions of currentdrinkers (Table 3). The proportion of current drinkers is indicated in brackets foreach group. Clearly the proportion of current drinkers (and conversely abstainersand past drinkers) differs among the various groups.


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Table 3: Types of beverage consumed and proportion of current drinkers(by race, gender, age)

Male Female

Africans, aged 10-21 Beer (m), spirits, wine,cider, beer (s) [39%-40%]

Wine, beer (m/s), cider[23%-32%]

Africans, aged 14+ Beer (m/s), spirits[77%-80%]

Wine, beer (m/s)[49%-66%]

Coloureds, aged 14+ Wine & beer (m), spirits[59%]

Wine, beer (m)[27%]

Asians, aged 14+ Beer (m) [49%] [8%]

Whites, aged 14+ Beer (m), wine, spirits[89%]

Wine, beer (m), spirits[77%]

Africans, aged 10-21(urban)

Beer (m), spirits, wine,cider, home-made liquor[40%]

Beer (m), wine, cider,home-made liquor, spirits[32%]

Africans, aged 10-21(rural)

Beer (m), spirits, wine,cider, home-made liquor[39%]

Wine, cider, Beer (m),home-made liquor, spirits[23%]

(m) malt, (s) sorghum

2.2.1.6 Major influences on substance useVarious factors have been put forward as contributing to substance use and abuse.For alcohol factors are likely to include peer pressure (particularly among youngpersons) and communal drinking among adults; availability, particularly in moredisadvantaged communities; the legacy of the dop system, particularly in theWestern Cape; ignorance; the falling price of certain kinds of alcohol products (e.g.malt beer and brandy) relative to the Consumer Price Index; chemical dependenceon alcohol; poor social conditions and boredom; a lack of social controls to deal withthose misusing substances; and societal attitudes in general (Parry & Bennetts, in

press; Rocha-Silva et al., 1996). With regard to availability/access, for example,there are currently almost 23 000 licensed liquor outlets with an estimated 150 000to 200 000 unlicensed outlets, yielding approximately one liquor outlet for every 190persons in South Africa (Parry & Bennetts, in press). Research has shown thatschool-going youth find it easy to purchase alcohol from bottle stores, supermarkets,bars and shebeens (Tibbs & Parry, 1994).

Local research has shown that the most common reasons reported for drug useinclude habit, to alter mood states, to improve health, to cope with personal, socialor interpersonal situations, or for enjoyment/taste (Rocha-Silva et al., 1996).Additional factors supporting the increase in illicit drug use in South Africa are likely

to include the falling real price of many drugs; poverty which is likely to haveincreased the street level trade in drugs; family breakdown and an increase in single


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parent households; increased availability as a result of increased trafficking of drugssuch as cocaine and heroin through South Africa which in turn may be due to factorssuch as the decrease in local controls following the collapse of Apartheid, increased

travel to South Africa as a result of increasing tourism and trade links, and increasedeconomic and political migration to South Africa -- together with changes in globalproduction, distribution and marketing of drugs in general. The increased use ofparticular drugs such as crack cocaine, may well be due to increased marketing ofcocaine due to a decrease in the US market as well as a (perhaps related) decreasein the quality of local Mandrax. The increase in the use of amphetamine typesubstances is probably due to the increase in the global production of thesesubstances and increased local marketing.

2.2.2 Reference to specific studies focussing on young persons

Several studies undertaken since 1990 have focussed specifically on substance usebehaviour among young persons. Given the focus of the Global Initiative, selectedfindings from these research studies will be provided

2.2.2.1 Research on AODs use by street children and persons attendingrave parties conducted as part of the SACENDU Project (1996-7)

As part of the SACENDU Project regular interviews with various groups of youngpersons have taken place. Such groups have included street children and personsattending rave parties. Focus group interviews with male and female street childrenin Cape Town at the end of 1996/early 1997 indicated that the main drug of choicefor street children appears to be paint thinners, followed by alcohol and cigarettes(Morojele, 1997a).

Research on persons attending rave parties in Cape Town was conducted at thebeginning of 1997 and approximately six months later. The research showed thatthe drugs that continue to be used at raves are Ecstasy and LSD, dagga/hashish toa lesser extent and also Speed, although its use has been on the decrease due to areduction in its availability. Drugs such as Mandrax and crack cocaine are not usedat raves since their effects are largely incompatible with taking part in anenvironment of high activity dance and high energy music. Among the numerousperceived positive consequences of the use of drugs during such dance events arethe drug effects of sociability and connectedness that are brought about throughEcstasy use and the altered consciousness and distorted and greater appreciationof sensations that result from the use of LSD. The major changes noted over thetwo six month data collection periods were (I) the decrease in the use of Speed andthe change in methods of its use by snorting (rather than being swallowed), (ii) asignificant decrease in the price of heroin, and (iii) an increase in the variation in thequality of Ecstasy (Morojele, 1997b).


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2.2.2.2 Research on binge drinking among adolescents conducted byUCT/MRC (1996-7)

Since 1995 several studies have been conducted by researchers at the Department

of Psychiatry at the University of Cape Town and at the National Urbanisation &Health Research Programme at the MRC. These have included a quantitative studyof drinking behaviour of 497 male and female students in Standard 8 (Grade 10) inthree high schools from different communities in the Cape Peninsula and aqualitative study involving a group of male binge drinkers and a group of male non-binge drinkers from each of the same three high schools.

In each of the studies the Theory of Planned Behaviour (Ajzen 1991) was used topredict/explain adolescents behaviour to engage or not to engage in binge drinkingbehaviour. According to the Theory of Planned Behaviour, the most directantecedent of a person s behaviour is his or her intention to carry it out. The direct

antecedents of the intention to perform a behaviour are attitudes towards thebehaviour, subjective norms and perceived behavioural control . Two additionalconstructs, moral obligation and self-identity were added as antecedents ofintention.In the first study (Morojele, Ziervogel, Parry & Robertson, 1997) found that 39% ofmales and 18% of females in the school in the middle class, predominately whitecommunity (School 1) engaged in binge drinking at least once during the past 14days as compared to 26% of males and 25% of females in the middle class,predominately Coloured community (School 2), and 36% of males and 4% offemales in the lower class, predominately African community (School 3). In all threeof the schools attitudes towards binge drinking and perceptions of control around

binge drinking were found to be significant and independent predictors of bingedrinking intentions. In School 3 motivations to binge drink were also found to besignificantly related to students subjective norms in relation to their behaviour. Selfidentity was found to be a useful predictor of binge drinking intentions fo r students inSchool 3 and for males in general, and moral obligation was a significant negativepredictor of females intentions to engage in binge drinking.

In the second study (Ziervogel, Morojele, Van der Riet, Parry & Robertson, 1997)focus group sessions were held with groups of binge drinkers and non-bingedrinkers from each of the three schools referred to earlier. Focus group discussionscentred around the concepts of the Theory of Planned Behaviour and the twoaddition concepts, moral obligation and self-identity. Binge drinkers appeared tofocus on the positive outcomes of binge drinking, and while aware of some of thenegative outcomes of such behaviour they had little awareness of their ownvulnerability. They tended to be more inclined to short-term gratification than thenon-binge drinkers and were embedded in a peer group culture which providednormative approval for binge drinking (attitude). They had limited motivation tocomply with parental wishes (subjective norms). They had few obstacles toobtaining alcohol (perceived behavioural control) and did not have serious moralobjections to binge drinking (moral obligation). For students in the binge drinkinggroup engaging in frequent consumption of alcohol was found to be an important

part of their self-identities (self-identity). For the non-binge drinking group, thenegative consequences of engaging in binge drinking appeared to outweigh the


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positives. They seemed to be more oriented towards achieving longer-termobjectives than the other group and many had had bad first experiences with alcohol(attitude). They appeared to be far more motivated to comply with parental wishes

(subjective norm) and were more likely to report difficulties in obtaining alcohol(perceived behavioural control). Most felt that it was wrong for persons of their ageto binge drink (moral obligation). For these students alcohol and social activitiesassociated with alcohol were found to be much less important to their self-identities(self-identity).

Based on these findings recommendations were made with regard to possiblestrategies to reduce binge drinking among young persons. For example it wasproposed that:

Interventions should be designed for the particular communities they are

meant to reach, that is, generic programmes may not be effective.

Life skills programmes should be designed to address the attitudes of youngpersons towards binge drinking, specifically attempting to modify adolescentsperceptions regarding the positive consequences of binge drinking and tointroduce less risky alternative activities which are also likely to lead topositive outcomes.

Strategies need to be formulated to reduce the perceived behavioural controlbinge drinkers experience, for example, strategies are needed to reduce theavailability of alcohol.

Life skills programmes should also take into account the influence ofnormative factors and self-identity on the intentions of males to engage inbinge drinking. This might best be achieved through programmes involvingvalues clarification or training in resistance-skills (refusing pressure to drink orto drink heavily). Young persons also need to be encouraged to have anappreciation of the need to plan ahead and to be equipped with the skills todo so. Peer-led programmes may be an effective mechanism for influencingadolescent norms and self-identity.

2.2.2.3 Research on AOD use among students at one high school in PortElizabeth conducted by SANCA (PE) (1997)

In February 1997 a survey of 328 students in Standards 9 and 10 (Grades 11 and12) at a high school in the northern areas of Port Elizabeth was undertaken. Theschool population comprised mainly coloured students as well as a number ofAfrican students. The lifetime prevalence of binge drinking (5 or more drinks on anyoccasion) was high: 45% of males and 40% of females in Standard 9, and 59% ofmales and 38% of females in Standard Grade 10 (Bayley, 1997). The lifetimeprevalence and percentage of current use of dagga and Mandrax is indicated inTable 4. Dagga is predominately used on special occasions, but seven studentsreported daily use of dagga and a further 6 reported using dagga two to three times

per week (out of 27 current users).


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Table 4: Lifetime prevalence and percentage of current use of dagga andMandrax (School in northern areas of Port Elizabeth, 1997)

Drug Standar d

Gender Life timeprevalence (%)

% reportingcurrent use

Dagga 10 Male 52 29

Female 14 3

9 Male 34 3

Female 13 4

Mandrax 10 Male 10 8

Female 0 0

9 Male 5 4

Female 2 2

2.2.2.4 Research on AOD use among high school students in Gautengand in the Cape Peninsula conducted by the Independent Order ofTrue Templars (IOTT) (1996)

In 1996 a study of AOD use was undertaken in 4 schools in the Western Cape and 5schools in Gauteng Province (Tibbs, 1996). The sample comprised 420 students in

Standard 6 (Grade 8). Students were predominantly African or coloured. Twenty-four percent of the students reported having drunk alcohol in the past 7 days, with21% of the students indicating that they had drunk 5 or more alcoholic drinks on atleast one occasion during the past 14 days. Various reasons were given for whyalcohol was first used (Figure 4).


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The lifetime prevalence of various drugs was as follows: dagga (10%; 17% - males,3% females), glue/thinners (4%), injectable drugs (3%), and other drugs excludingtobacco (7%). A large proportion of students indicated that regular use of different

substances leads to no harm: dagga (26%), LSD (25%) and binge drinking (31%). Ahigh percentage of the students reported having family members with drinking ordrug problems (42%). Forty-five percent of the students reported coming fromfamilies that seldom did things together and the same percentage reported that theirparents were mostly unaware of where they were or what they were doing. Whenasked who had first introduced them to alcohol, 58% reported their friends followedby their siblings (25%) and parents (19%). When it came to dagga, parents wereranked first, ahead of friends. Over half (58%) believed that prevention andeducation programmes about drugs were important for everyone in the community(Tibbs,1996).

2.2.2.5 Research on AOD use among black youth ages 10-21 yearsconducted by the HSRC (1994)

In a survey of 1378 African young persons aged 10-21 from urban and rural areas inSouth Africa, Rocha-Silva et al. (1996) found that 11.3% of urban males and 19.6%of rural males consumed on average 10cl of absolute alcohol on average per day(equivalent to almost five 340ml beers). The corresponding percentages for femaleswere 6.1% in urban areas and 7.7% in rural areas (see also Tables 2 and 3 above).

Besides dagga use by urban males (5.5%), very little current use of illicit drugs wasreported by males or females in either the urban or rural samples. Within thecombined sample, self-reported lifetime use of various substances was as follows:

LSD (1.9%), Mandrax (1.7%), cocaine (0.9%), heroin (0.9%), Ecstasy (0.1%), non-prescriptive narcotics other than heroin (2.1%), and steroids (2.0%). Self-reporteduse of these substances in the last 12 months was as follows: LSD (1.5%), Mandrax(1.7%), cocaine (0.8%), heroin (0.9%), non-prescriptive narcotics other than heroin(2.1%), and steroids (2.9%).

Over half of the urban males started using dagga between 14 and 17 years of age.For young persons in urban and rural areas, both males and females, the use ofsolvents generally started between the ages of 10 and 13. These substances weregenerally first obtained through friends. The most common context within whichalcohol is consumed for urban and rural males was at a shebeen, tavern or homewhere they have to pay for their drink. For urban females it was at the home offriends where they either bring their own drink or get it for free. For rural females itwas at home/the place where they live.


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2.2.2.6 Research on adolescent risk behaviour based on surveys of highschool youth and high school drop-outs in the Cape Peninsulaconducted by UCT/MRC (1990-91)

Flisher, Ziervogel, Chalton, Leger & Robertson (1993a/b) reported on a 1990 surveyof AOD use in a sample of 7340 high school students in 16 schools in the CapePeninsula. The sample comprised students from all race groups in the area.Findings were reported by descriptive variables such as language, gender andstandard. They later reported on a similar survey of 68 coloured high school drop-outs (Flisher & Chalton, 1995). The proportions indicating that they had engaged inbinge drinking (five or more drinks on at least one occasion during the past 14 days)are shown in Figure 5.

Levels of binge drinking are clearly higher in the drop-out sample than in the schoolgoing sample (but this could be an due to the drop-out sample being older).Amongst the school-going sample binge drinking was higher in males than females.It was particularly high in English and Xhosa-speaking males and particularly low inthe Xhosa-speaking females. In general the prevalence of binge drinking appearedto increase with standard (age).

Among the school-going sample the lifetime prevalence of dagga use was 7.5%, and2.4% reported using dagga at least once in the past 7 days. More males thanfemales for each standard and language group had smoked dagga and there was atrend of increased lifetime use with standard. The proportion of Xhosa-speakingfemales who had used dagga was particularly small. More males than femalesreported recent use for each standard and language group. For both genders thevariation between standards was not marked. A relatively large proportion (10%) ofXhosa-speaking males reported recent dagga use. Of Xhosa-speaking males, 2.3%

reported using dagga and Mandrax together.


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Reported lifetime use of injectable drugs was 0.5%, and 0.2% had used them atleast once in the past 7 days. Reported use of drugs such as cocaine, heroin, LSDand opium was rare. Lifetime use (sniffing) of solvents such as glue, petrol or

thinners was 10.9%. Less than 3% of the sample reported sniffing solvents at leastonce in the past 7 days.

Data (collected in 1997) from two further studies are currently being analysed andfindings should be available by the middle of 1998. Both have been conducted byresearchers from UCT and the MRC. The one involves a study of ATOD use inapproximately 3000 high school students in Standards 6 and 9 (Grades 8 and 11) inCape Town and the other is an 18 month follow up of drinking behaviour among400+ students in three schools in Cape Town comprising students from widelydiffering backgrounds.

2.3 Health and social problems arising from AOD use by young persons in SouthAfrica

Research in the area of AOD use and young people in South Africa has tended tofocus on issues such as the assessment of the nature and extent of substance use,risk factors associated with substance use, and reasons for substance use/abuse.There has been very little research into social and health consequences associatedwith AOD use by young people in this country (Parry, 1997). Data from theSACENDU Project (Parry & Bhana,1997), however, support the view that youngpersons in South Africa and the country are burdened as a result of the use of AODsby young persons. For example:

26% of persons arrested by the South African Narcotics Bureau (SANAB) fordealing in illicit substances in Cape Town the second half of 1996 werejuveniles, up from 8% in the previous six months.Analysis of statistics provided by specialist treatment centres in Cape Town inthe second half of 1996 and in the first half of 1997 reveals that approximately6% of all admissions are for persons under 20 years of age.

Investigations of AOD use among cases seen at trauma units and the mortuaries arelikely to support the view that the use of these products can have serious and evenfatal consequences for young persons and place a heavy burden economically andin other ways upon society. One topic which has been very little studied in SouthAfrica is the effect of substance use on school performance. Yamada, Kendix &Yamada (1996) in a study using data from the US National Longitudinal Survey ofYouth found that increases in the incidence of frequent drinking, liquor and wineconsumption, and frequent cannabis (dagga) use significantly reduce the probabilityof high school graduation.


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3. CURRENT PREVENTION WORK IN SOUTH AFRICA WITH YOUNGPEOPLE

There are a range of initiatives directed towards preventing substance abuse amongyoung persons in South Africa. I presume this section will be covered at length bythe delegates from the South African (national) Departments of Health and Welfareand from the National Office of SANCA. The ones that I am particularly familiar withare listed below (by the agencies most responsible for their design andimplementation):

3.1 Department of WelfareThe national and provincial Department of Welfare embarked upon a nationalschool-based education initiative, I m addicted to life . It was launched in

May 1995 and was aimed at teenagers between the ages of 11 and 20. Thetelevision series involved 13x9 minute episodes and 13x2 minuteendorsements which were flighted in the afternoons and evenings. 13x3minute radio spots in 11 languages were also produced. In addition, 13x30second personality endorsements were produced and flighted. Anti-drugposters were produced and distributed to every school in the country and ananti-drug pledge campaign initiated. Information leaflets were also producedand distributed to the schools. The campaign has also been expanded toinclude a video and teacher s manual.

An independent evaluation of the campaign was undertaken by market

research company. Ninety-six percent of the 265 young persons interviewedfrom around the country had heard of the campaign, with the percentagebeing highest among respondents in Standard 10 (Grade 12) and students intertiary education (100%), and lowest among respondents in Standards 6 and7 (93%). Respondents were asked whether they felt that the campaign was agood idea and whether it would influence young people not to take drugs.According to the evaluation report there was complete consensus that thecampaign is a good idea. On reflection it is clear that this was a very softevaluation. A more rigorous evaluation would require a pre- and post-intervention evaluation of changes in knowledge, attitudes, intentions andpreferably behaviour.

3.2 The Department of Education

The national Department of Education is currently involved in implementing itsCurriculum 2005" initiative, which amongst other things is supposed to

include a life skills education component which will also seek to preventsubstance use/abuse. The International Center for Alcohol Policies (ICAP),based in Washington is also working with the provincial Department ofEducation in Northwest Province (and in Botswana) to design a life skillseducation programme aimed at primary school age children. The projectspecifically involves (I) developing life skills materials for use in five schools,(ii) training teachers in the use of these materials, and (iii) testing thesematerials in the teacher s classroom for one academic year.


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3.3 Soul City 3Soul Cityis a multi-media health education/counter-advertising initiativeseeking to address a range of risk behaviours including alcohol and smoking

through a very popular prime-time sitcom aired on TV as well as on radio (inthe vernacular), and via the print media (a handbook serialised innewspapers). The series on alcohol included 14 prime time TV episodes runover three months. Focus groups involving young persons and adults(separately) were run as part of the pre-testing of material to be used in SoulCity 3 It is currently being evaluated by CASE (Community Agency for SocialEnquiry).

As a result of the evaluation of the second series ofSoul Cityon tobacco,AIDS, TB and housing, it was noted that:

the TV series was rated 2nd among the total adult population

51% of Africans watched it regularly61% of persons sampled saw/read or listened to Soul City70% of 16-24 years olds sampled saw/read or listened to Soul City51% of persons with no formal education sampled saw/read or listenedto Soul City.

3.4 Industry Association for Responsible Alcohol (ARA)ARA has been involved in running the Buddy Campaign for almost a decadeon university and technikon campuses. The objective is to focus the minds ofyouth on the dangers of alcohol misuse and abuse. ARA members have alsosupported life skills education programmes around the country. Theseprogrammes reach some 1 000 schools. The Buddy Campaign wasevaluated by the HSRC in 1993 and it was noted that there was an increasein the awareness of the dangers of alcohol misuse among young persons asa result of the programme.

3.5 SANCA s TADA and POPPETS initiativesThe POPPETS (Programmes of Primary Prevention through Stories)programme is aimed at the pre-primary and early primary school child(primarily 5-9 years old). Puppets, stories and games are used to educatethe child. Information on alcohol and drugs is provided as well as skillstraining to address issues such as self-image and peer pressure. The TADA

(Teenagers Against Drug Abuse) programme involves the setting up of youthaction groups in high schools or youth groups (after hours). It aims toprevent substance abuse among peers and promotes exciting alternatives.SANCA acts as the facilitator providing groups with training and support.Young persons are encouraged to take an increasingly greater responsibilityfor running the TADA groups. These programmes are thought to be verysuccessful, but have not been formally evaluated as far as I am aware.

3.6 CTDCC Schools Drug Education and Prevention ProgrammeA new and potentially very exciting initiative has been started in Cape Townand should involve approximately 50 schools. The programme is being

implemented by the Cape Town Drug Counselling Centre (CTDCC) withfunding from USAID, the Royal Netherlands Embassy, and the Transitional


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National Development Trust (TNDT). The key components of this programmecomprise:

Initial briefing sessions to all teaching and guidance staff in each

schoolDrug education and prevention workshops delivered to schoolstudentsA six week course for guidance teachers at CTDCCAn educational video on drug prevention to be provided to each schoolA teacher s manual, information leaflets and posters to be provided foreach school.

The primary strengths of this initiative are:The six month involvement with each schoolThe comprehensive training of one guidance teacher from each school

at CTDCCThe development of rapid referral arrangements from schools for drugdependant pupilsThe provision of library resources to each school, i.e. life skills videos,teachers manuals, and reference literature.

3.7 Lions International (Lions Quest Skills for Adolescents Programme)This project runs in various parts of the country. In the Western CapeProvince alone this programme is currently running in over 45 schools. TheLions Quest Skills for Adolescents Programme is designed to combat alcoholand drug abuse among young persons by teaching them social life skills.The focus of the programme is not on the substance abuse problem alonebut rather on the proposed causes of the problem; issues such as poor selfimage, inability to resist peer pressure, poor family relationships, lack ofdecision making skills and poor communication ability. The main objective istherefore to teach adolescent youth pro-social life skills thereby giving themthe opportunity to be who and what they themselves want to be.

Evaluation was undertaken to see whether the programme was suitable forthe South African situation (Crous, Lessing, Schultze, & Sonnekus, 1993).The design used was a pre-test/post-test control group design. Six privateschools took part in the study. One class from each school formed anexperimental group (N=171) and a second class formed a control group(N=176). The 120-item social attributes questionnaire was administered bothpre- and post-test. This questionnaire was developed to assess six life skills:self confidence, coping with emotions, resisting peer pressure, improvingfamily relationships, decision making skills and goal setting. In addition, theinterpersonal relationship questionnaire was also developed. The resultsshowed that the average score on the social attitudes questionnaire wassignificantly higher at post-test for the experimental than the control group.For the interpersonal relationship questionnaire, contrary to expectations, theresults of the post-test showed that the control group showed more

improvement than the experimental group.


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3.8 Other education initiativesMany other school-based and after-school initiatives have been establishedby various governmental organisations and NGOs. Many involve one-off

lectures. Some include evaluation forms which are filled in the students, andwhich assess the quality of the programme in terms of whether the studentsfound the input useful. A number of programmes are listed below by theagency providing the programmes in the schools:

1. Bridges - a school-based programme in the Western Cape run byrecovering addicts.

2. Young Caring Community - aimed at pre-primary, primary,secondary school going students and church-going youth. It is basedin the Western Cape. Information is provided through talks, videopresentations and workshops/presentations. Youth clubs are also

being launched.3. South African Police Services (SAPS) members give talks in

schools (national).4. Narcotics Anonymous (NA) runs peer education programmes in

various schools nationally. The Drug Free Marshals Programme issponsored by the Church of Scientology. Marshals are drawn from theranks of primary and high schools. They are expected to follow adrug-free lifestyle, which involves showing their friends how muchmore fun a drug-free lifestyle can be. They are also charged withlearning more about drugs, their harmful effects, and how to getinformation across in an exciting format. More than 30 schools across

South Africa have signed up marshals.5. DrugWise Counsellors gives talks in the schools and prepares

educational materials (national)6. Horizon Programme -- This programme is run as a Christian ministry.

It has 215 branches and approximately 6 200 members.7. Alcohol Drug Concerns (ADC).8. International Order of True Templars (IOTT).9. Youth for Christ (national).

3.9 Programmes for street-children

There are various programmes for street children designed to address manyproblems facing this population including substance abuse, e.g. StreetWise inJohannesburg and the Homestead Programme in Cape Town.

3.10 Other Alcohol Safety Schools have been established in various parts of the country.Talks and video presentations are given to individuals who have beenreferred by the courts. There are no doubt several other innovativesubstance abuse prevention programmes in individual communities of which Iam not fully aware (e.g. in Shoshanguve and in Mangaung).


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Major gaps exist with regard to a comprehensive approach to the prevention ofalcohol misuse, for example, programmes directed towards high-school dropouts,and persons living in rural areas.

There are several NGOs which I believe could be invited to become local partners inthe Global Initiative:

1. National Progressive Primary Health Care Network (NPPHCN)2. SANCA (Regional affiliates directly or through National Office)3. Soul City4. StreetWise5. Cape Town Drug Counselling Centre

I am sure that the other colleagues from South Africa will be able to identify CBOswhich are doing innovative work in the substance abuse area which could be

proposed as suitable partners in the WHO/UNDCP initiative.

4. SUPPORT FOR GLOBAL INITIATIVE ACTIVITIES

4.1 Regional, national and local bodies which incorporate primary preventionapproaches related to young people and substance use issues

There are several regional, national and local bodies which incorporate primaryprevention approaches related to young people and substance use issues (see 3above).

4.2 Country/regional resources to support youth related primary preventioninitiatives

It is possible that youth related substance abuse primary prevention initiatives couldget support from some of the following organisations:

National and provincial welfare departments

SANCA Information and Resource Centre (SIRC) based inJohannesburgSubstance abuse (or Alcohol and Drug Abuse) Prevention Forums inmost of the provincesDrugWise Pharmacists (national office in Norwood)Research Councils (e.g. HSRC, MRC, CSIR)


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4.2.1 Grant programmesNational Youth Commission may have funding for youthdevelopment initiatives

Reconstruction & Development Programme -- may have funding forbroad development initiativesTransitional National Development Trust (TNDT) - has funding forNGO and NGO projectsWHO/UNDP Global Initiative for the Prevention of SubstanceAbuse in South Africa -- funding was provided for 8 projects (5 ofwhich were primary prevention projects) in 1996/7. Some of theunspent funds from this project may still be available for furtherprevention projects.From time to time other governments make funds available whichcould possibly be tapped in to for substance abuse prevention. USAID

and the Royal Netherlands Embassy have, for example, providedfunding for CTDCC starting 1998 for schools-based substance abuseprevention.Other international Funding Programmes could perhaps be tapped into e.g. EU, UNDP, UNDCP, UNAIDS.

4.2.2 Materials dealing with primary preventionVarious materials have been developed over the years (posters, booklets,videos, etc) relating to I m addicted to life programme, Soul City,TADA/POPPETS programme, etc. Material have also been produced by Pickn Pay, the Department of Health and Welfare, DrugWise, etc.

4.2.3 National/International experts/consultants active in this areaThere are very few national or international consultants working in this areawho are working, or who have considered working, in South Africa. Some ofthose I am aware of are:

Peter Sjorquist (Global Rock Challenge Australia)Dr Vince Bateman and staff at the Human Resources DevelopmentInstitute (HDRI) in ChicagoCornell Taljaard and Orne Louw (Institute for Health Training &Development - Johannesburg)

David Jernigan (Marin Institute - San Rafael, California)Life Education AustraliaNetherlands Institute on Alcohol and Drugs

4.3.4 Training required for NGOs/CBOsAll of the following. Equally important.

Principles of primary preventionProgrammes found to be effective in other countriesLocal situation assessmentProject designProject management

Project monitoring and evaluation.


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4.3.5 Access to InternetThere is ready access to the Internet throughout the country (technicallyspeaking), but most NGOs and CBOs do not have the infrastructure or funds

to enable Internet access. There are a range of Internet Service Providers(ISPs). Access to computers is a major obstacle, particularly in rural areas. Afew of the larger NGOs e.g. SANCA National has access to the Internet.SANCA National has a resource centre (the SANCA Information andResource Centre) with a full time Information Specialist who would probablybe able to assist NGOs and CBOs requiring access to material on theInternet. There are Internet Caf s in many of the larger cities wherepersons/organisations can purchase time on the Internet. Most NGOs andCBOs would have access to a fax machine. Several local agencies workingin the substance abuse area (directly or indirectly) have home pages on theWorld Wide Web:

SANCA s Information & Resource Centre: http://wn.apc.org/sanca/The MRC s Mental Health & Substance Abuse Division s home pagehas links to various local and international prevention resources:http://www.mrc.ac.za/urban/hotlinks.htmThe South African Brain Research Institute:http://os2.iafrica.com/sabri/The Crime Information Management Centre:http://www.saps.co.za/8_crimeinfo/8_index.htmThe Institute for Health Training and Development

http://wn.apc/org/sanca/ihtd

5. CONCLUSION

Epidemiologists, service providers, educators, law enforcement authorities and thegeneral public in South Africa and have a strong suspicion that AOD use amongyoung persons is increasing. This is supported, for example, by the finding thatmany specialist treatment centres are being approached by younger clients and byreports that police in certain locations are arresting younger persons for dealing in orpossession of drugs. Such findings could, however, reflect other factors such as

police policies or changing admission policies. The findings of research undertakenby the University of Cape Town and the MRC as part of the SACENDU Project onhigh school students in Cape Town will be released within the next few months.This will allow a determination to be made of changes in the prevalence ofsubstance use over a seven year period (1990-1997) in a comparable group ofstudents. Such information is vital to the planning of preventive interventionstargeting young persons and influencing policy at local, provincial and nationallevels.

It is encouraging that the draft Framework for a national drug master plan releasedby the South African Minister of Welfare in October 1997 identifies motivating ouryouth to reject illegal drug use and substance abuse by preventive education and byreducing acceptability and availability of drugs to young people as one of its three


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priorities (Drug Advisory Board, 1997, p. 25) . The broad agenda has been set.What remains is to identify specific programmes which are likely to be effective.The UNDCP/WHO Global Initiative on Primary Prevention of Substance Abuse

through supporting the development, implementation and evaluation of modelprevention programmes in different countries in the sub-continent has the potentialfor greatly assisting our country and others in this process.

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